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Casus 3
De Casus Je bent waarnemend huisarts. Op je spreekuur zie je vier patiënten met rugklachten als gevolg van hun aandoening: Differentiaal Diagnose Back pain is a symptom. Common causes of back pain involve disease or injury to the muscles, bones, and/or nerves of the spine. Pain arising from abnormalities of organs within the abdomen, pelvis, or chest may also be felt in the back. This is called referred pain. Many disorders within the abdomen, such as [http://www.emedicinehealth.com/script/main/art.asp?articlekey=58649 appendicitis], [http://www.emedicinehealth.com/script/main/art.asp?articlekey=59394 aneurysms], kidney diseases, [http://www.emedicinehealth.com/script/main/art.asp?articlekey=97630 kidney infection], bladder infections, pelvic infections, and ovarian disorders, among others, can cause pain referred to the back. Normal [http://www.emedicinehealth.com/script/main/art.asp?articlekey=58752 pregnancy] can cause back pain in many ways, including stretching ligaments within the pelvis, irritating nerves, and straining the low back. Your doctor will have this in mind when evaluating your pain. Nerve root syndromes are those that produce symptoms of nerve impingement (a nerve is directly irritated), often due to a [http://www.emedicinehealth.com/script/main/art.asp?articlekey=59262 herniation (or bulging) of the disc] between the lower back bones. [http://www.emedicinehealth.com/script/main/art.asp?articlekey=59259 Sciatica] is an example of nerve root impingement. Impingement pain tends to be sharp, affecting a specific area, and associated with numbness in the area of the leg that the affected nerve supplies. *Herniated discs develop as the spinal discs degenerate or grow thinner. The jellylike central portion of the disc bulges out of the central cavity and pushes against a nerve root. Intervertebral discs begin to degenerate by the third decade of life. Herniated discs are found in one-third of adults older than 20 years of age. Only 3% of these, however, produce symptoms of nerve impingement. *Spondylosis occurs as intervertebral discs lose moisture and volume with age, which decreases the disc height. Even minor [http://www.emedicinehealth.com/script/main/art.asp?articlekey=8171 trauma] under these circumstances can cause inflammation and nerve root impingement, which can produce classic sciatica without disc [http://www.emedicinehealth.com/script/main/art.asp?articlekey=40106 rupture]. *Spinal disc degeneration coupled with disease in joints of the low back can lead to spinal-canal narrowing ([http://www.emedicinehealth.com/script/main/art.asp?articlekey=98276 spinal stenosis]). These changes in the disc and the joints produce symptoms and can be seen on an [http://www.emedicinehealth.com/script/main/art.asp?articlekey=58739 X-ray]. A person with spinal stenosis may have pain radiating down both lower extremities while standing for a long time or walking even short distances. *[http://www.emedicinehealth.com/script/main/art.asp?articlekey=59305 Cauda equina syndrome] is a medical emergency whereby the spinal cord is directly compressed. Disc material expands into the spinal canal, which compresses the nerves. A person would experience pain, possible loss of sensation, and bowel or bladder dysfunction. This could include inability to control urination causing [http://www.emedicinehealth.com/script/main/art.asp?articlekey=79215 incontinence] or the inability to begin urination. Musculoskeletal pain syndromes that produce low back pain include myofascial pain syndromes and [http://www.emedicinehealth.com/script/main/art.asp?articlekey=59229 fibromyalgia]. *Myofascial pain is characterized by pain and tenderness over localized areas ([http://www.emedicinehealth.com/script/main/art.asp?articlekey=30700 trigger] points), loss of [http://www.emedicinehealth.com/script/main/art.asp?articlekey=5208 range of motion] in the involved muscle groups, and pain radiating in a characteristic distribution but restricted to a peripheral nerve. Relief of pain is often reported when the involved muscle group is stretched. *Fibromyalgia results in widespread pain and tenderness throughout the body. Generalized stiffness, [http://www.emedicinehealth.com/script/main/art.asp?articlekey=58902 fatigue], and muscle aches are reported. Infections of the bones (osteomyelitis) of the spine are an uncommon cause of low back pain. Noninfectious inflammation of the spine (spondylitis) can cause stiffness and pain in the spine that is particularly worse in the morning. Ankylosing spondylitis typically begins in adolescents and young adults. Tumors, possibly cancerous, can be a source of skeletal pain. Inflammation of nerves from the spine can occur with infection of the nerves with the herpes zoster virus that causes [http://www.emedicinehealth.com/script/main/art.asp?articlekey=58876 shingles]. This can occur in the thoracic area to cause upper back pain or in the lumbar area to cause low back pain. Anamnese Aanvullend Onderzoek Behandeling [http://www.emedicinehealth.com/script/main/art.asp?articlekey=58735 Medication] treatment options depend on the precise diagnosis of the low back pain. Your doctor will decide which medication, if any, is best for you based on your medical history, allergies, and other medications you may be taking. *Nonsteroidal anti-inflammatory medications (NSAIDs) are the mainstay of medical treatment for the relief of back pain. Ibuprofen, [http://www.emedicinehealth.com/script/main/art.asp?articlekey=101939 naproxen], [http://www.emedicinehealth.com/script/main/art.asp?articlekey=101849 ketoprofen], and many others are available. No particular [http://www.emedicinehealth.com/script/main/art.asp?articlekey=4592 NSAID] has been shown to be more effective for the control of pain than another. However, your doctor may switch you from one NSAID to another to find one that works best for you. *COX-2 inhibitors, such as [http://www.emedicinehealth.com/script/main/art.asp?articlekey=102426 celecoxib] (Celebrex), are more selective members of NSAIDs. Although increased cost can be a negative factor, the incidence of costly and potentially fatal bleeding in the gastrointestinal tract is clearly less with COX-2 inhibitors than with traditional NSAIDs. Long-term safety (possible increased risk for [http://www.emedicinehealth.com/script/main/art.asp?articlekey=58679 heart attack] or [http://www.emedicinehealth.com/script/main/art.asp?articlekey=59414 stroke]) is currently being evaluated for COX-2 inhibitors and NSAIDs. *Acetaminophen is considered effective for treating acute pain as well. NSAIDs do have a number of potential side effects, including gastric irritation and kidney damage, with long-term use. *Muscle relaxants: Muscle [http://www.emedicinehealth.com/script/main/art.asp?articlekey=11248 spasm] is not universally accepted as a cause of back pain, and most relaxants have no effect on muscle spasm. Muscle relaxants may be more effective than a placebo (sugar pill) in treating back pain, but none has been shown to be superior to NSAIDs. No additional benefit is gained by using muscle relaxants in combination with NSAIDs over using NSAIDs alone. Muscle relaxants cause drowsiness in up to 30% of people taking them. Their use is not routinely recommended. *[http://www.emedicinehealth.com/script/main/art.asp?articlekey=13744 Opioid] analgesics: These drugs are considered an option for pain control in acute back pain. The use of these medications is associated with serious side effects, including dependence, sedation, decreased reaction time, [http://www.emedicinehealth.com/script/main/art.asp?articlekey=4510 nausea], and clouded judgment. One of the most troublesome side effects is [http://www.emedicinehealth.com/script/main/art.asp?articlekey=59275 constipation]. This occurs in a large percentage of people taking this type of medication for more than a few days. A few studies support their short-term use for temporary pain relief. Their use, however, does not speed recovery *[http://www.emedicinehealth.com/script/main/art.asp?articlekey=98554 Steroids]: Oral steroids can be of benefit in treating acute sciatica. [http://www.emedicinehealth.com/script/main/art.asp?articlekey=100122 Steroid injections] into the epidural space have not been found to decrease duration of symptoms or improve function and are not currently recommended for the treatment of acute back pain without sciatica. Benefit in [http://www.emedicinehealth.com/script/main/art.asp?articlekey=59398 chronic pain] with sciatica remains controversial. Injections into the posterior joint spaces, the facets, may be beneficial for people with pain associated with sciatica. Trigger point injections have not been proven helpful in acute back pain. Trigger point injections with a steroid and a local anesthetic may be helpful in chronic back pain. Their use remains controversial. Prognose